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Acute pancreatitis College 2010 EJ Hazebroek, chirurgie JF Monkelbaan, MDL ziekten.

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Presentatie over: "Acute pancreatitis College 2010 EJ Hazebroek, chirurgie JF Monkelbaan, MDL ziekten."— Transcript van de presentatie:

1 Acute pancreatitis College 2010 EJ Hazebroek, chirurgie JF Monkelbaan, MDL ziekten

2 What is it? Inflammation with or without parenchymal and peripancreatic fat necrosis Classified as acute or chronic Acute – “acute onset of symptoms in a previously healthy individual and the disappearance of those symptoms as the attack resolves” Chronic – patients either had prior attacks or pancreatic insufficiency; symptoms may persist Pancreatitis

3 Why does it happen? Obstruction, trauma, toxin Acinar cell injury Intrapancreatic inflammatory response Systemic inflammatory response

4 Buizenstelsel van lever, gal en pancreas

5 Pancreatitis: acuut versus chronisch ACUTE PANCREATIS 1 Episode van inflammatie, op zich zelf staand of als begeleidend verschijnsel van een andere aandoening. 2 Kan volledig genezen, maar kan ook voortschreiden tot een hemorrhagische, necrotiserende vorm die levensbedreigend kan zijn. CHRONISCHE PANCREATIS 1.Een geprotraheerde inflammatie gekarakteriseerd door permanente veranderingen van de anatomie, functionele afwijkingen, ook al is de oorzaak weggenomen. 2. in voortgeschreden gevallen afname exocriene en endocriene functie

6 Acute pancreatitis: definitie Acute pancreatitis - may occur as isolated or as recurrent attacks - is distinguished from chronic pancreatitis by absence of continuing inflammation of irreversible structural changes of permanent impairment of pancreatic function function Rome 1988

7 Acute pancreatitis: pathogenese 1. Obstructie van secretie 2. Reflux van duodenum inhoud 3. Reflux van gal 4. Verhoogde permeabiliteit van het d. pancreaticus epitheel 5. Premature zymogeen activatie

8 Acute pancreatitis: pathogenese 1. Obstructie van secretie 2. Reflux van duodenum inhoud 3. Reflux van gal 4. Verhoogde permeabiliteit van het d. pancreaticus epitheel 5. Premature zymogeen activatie

9 Acute pancreatitis: pathogenese 1. Obstructie van secretie 2. Reflux van duodenum inhoud 3. Reflux van gal 4. Verhoogde permeabiliteit van het d. pancreaticus epitheel 5. Premature zymogeen activatie

10 biliary alcoholism other causes unknown Acute pancreatitis: ethiologie - medication - hyperlipidaemia - ERCP - trauma - hypercalciaemie - pregnancy - penetrating ulcer - organ transplantation - hereditary

11 Acute pancreatitis: prognosis RANSON’S CRITERIA revision by Hollender et al, 1983 (acute, ethanol-associated) (acute, ethanol-associated) Early findings Age > 55 yrs Serum glucose > 200 mg/dl Leucocytosis > LDH > 350 U/l Control findings hrs after onset of illness) Ht reduction > 10% Serum calcium < 2 mmol/l Base deficit > 4 mmol/l Arterial pO 2 < 60 mm Hg Fluid deficit > 6 liter

12 Acute pancreatitis: prognosis GLASGOW CRITERIA (acute, non-ethanol-related) White cell count > Blood glucose > 10 mmol/l BUN > 16 mmol/l Arterial PO 2 < 60 mmHg Serum Ca < 2 mmol/l Serum Albumen <32 g/l LDH > 600 U/l ASAT or ALAT > 200 U/l

13 Acute pancreatitis

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15 TREATMENT GOALS TREATMENT GOALS - SUPPORTIVE CARE - REDUCE INFLAMMATION - ASSESS AND TREAT COMPLICATIONS

16 Management of acute necrotizing pancreatitis Prophylactic antibiotics ? ERCP and Biliary sphincterotomy ? Nutritional support: TPN or Enteral feeding (jejunal feeding) ? Surgical debridement (Necrosectomy) ?

17 Acute pancreatitis SUPPORTIVE CARE Essential - Close clinical surveillance - NPO - IV fluid replacement - Nutritional support - Relief of pain No proven benefit - antibiotics ? - atropine - calcitonine - glucagon - somatostatine - H2 blockers - antifibrinolytics - phospholipase A2 inhibitors ? - IL-10 ?

18 Chronische pancreatitis Chronic pancreatitis: pathophysiology - > 60-70% alcohol % idiopathic - hereditary - miscellaneous (hyperparathyroidism, Sjogren’s, SLE)

19 Chronische pancreatitis Chronic pancreatitis: clinical presentation - (severe) pain - diabetes mellitus - steatorrhea

20 Chronische pancreatitis Therapy of chronic pancreatitis - Avoiding nutritive noxas (in 90% alcohol!) - Treatment of endocrine and exocrine insufficieny - Pain control and correction of pancreatic complications AAA Pancreatin substitution Reduction of fat In cachexia gastric feeding tube Opiate analogs, neuroanaleptics Celiac ganglion blockade Surgery


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